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Bakhriansyah M, Souverein PC, de Boer A, Klungel OH. Gastrointestinal toxicity among patients taking selective COX-2 inhibitors or conventional NSAIDs, alone or combined with proton pump inhibitors: a case-control study. Pharmacoepidemiol Drug Saf 2017; 26:1141-1148. [PMID: 28370857 PMCID: PMC5655916 DOI: 10.1002/pds.4183] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 01/12/2017] [Accepted: 01/22/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the risk of gastrointestinal perforation, ulcers, or bleeding (PUB) associated with the use of conventional nonsteroidal anti-inflammatory drugs (NSAIDs) with proton pump inhibitors (PPIs) and selective COX-2 inhibitors, with or without PPIs compared with conventional NSAIDs. METHODS A case-control study was performed within conventional NSAIDs and/or selective COX-2 inhibitors users identified from the Dutch PHARMO Record Linkage System in the period 1998-2012. Cases were patients aged ≥18 years with a first hospital admission for PUB. For each case, up to four controls were matched for age and sex at the date a case was hospitalized (index date). Logistic regression analysis was used to calculate odds ratios (ORs). RESULTS At the index date, 2634 cases and 5074 controls were current users of conventional NSAIDs or selective COX-2 inhibitors. Compared with conventional NSAIDs, selective COX-2 inhibitors with PPIs had the lowest risk of PUB (adjusted OR 0.51, 95% confidence interval [CI]: 0.35-0.73) followed by selective COX-2 inhibitors (adjusted OR 0.66, 95%CI: 0.48-0.89) and conventional NSAIDs with PPIs (adjusted OR 0.79, 95%CI: 0.68-0.92). Compared with conventional NSAIDs, the risk of PUB was lower for those aged ≥75 years taking conventional NSAIDs with PPIs compared with younger patients (adjusted interaction OR 0.79, 95%CI: 0.64-0.99). However, those aged ≥75 years taking selective COX-2 inhibitors, the risk was higher compared with younger patients (adjusted interaction OR 1.22, 95%CI: 1.01-1.47). CONCLUSIONS Selective COX-2 inhibitors with PPIs, selective COX-2 inhibitors, and conventional NSAIDs with PPIs were associated with lower risks of PUB compared with conventional NSAIDs. These effects were modified by age. © 2017 The Authors. Pharmacoepidemiology & Drug Safety Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Mohammad Bakhriansyah
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, The Netherlands.,Department of Pharmacology, Medical Faculty, Lambung Mangkurat University, Banjarmasin, Indonesia
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, The Netherlands
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Effect of polypharmacy and potentially inappropriate medications on treatment and posttreatment courses in elderly patients with head and neck cancer. J Cancer Res Clin Oncol 2016; 142:1031-40. [DOI: 10.1007/s00432-015-2108-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
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3
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[Gastroprotection in the patient of advanced age: When and how]. Rev Esp Geriatr Gerontol 2012; 47:93-5. [PMID: 22575424 DOI: 10.1016/j.regg.2012.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 02/22/2012] [Indexed: 01/27/2023]
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Esomeprazole relieves upper gastrointestinal symptoms in high-risk and average-risk NSAID users in daily clinical practice: results from an open-label study. Eur J Gastroenterol Hepatol 2012; 24:281-7. [PMID: 22246328 DOI: 10.1097/meg.0b013e32834f4d19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To investigate whether esomeprazole can provide relief for nonsteroidal anti-inflammatory drug (NSAID)-associated upper gastrointestinal symptoms in patients at different gastrointestinal risk. METHODS A multicentre, prospective, open-label study was conducted, wherein NSAID users visiting their general practitioner for upper gastrointestinal symptoms were asked to participate. Patients were treated with 20 mg esomeprazole and treatment effect was evaluated within 8 weeks. Response was defined as a maximum of 1 day per week with gastrointestinal symptoms during the last week of treatment. Partial response was defined as more than 50% improvement in the number of days per week with symptoms compared with baseline. Patients not meeting the above-mentioned criteria were classified as nonresponders. Patients who completely responded were compared with partial responders and nonresponders and were analysed according to their baseline gastrointestinal risk. RESULTS A total of 1042 patients (mean age: 57 years; standard deviation: 15; 43% male) were analysed. Complete response, partial response and nonresponse were achieved in 57, 24 and 19% of the patients, respectively. Similar response was seen in average-risk and high-risk patients (58 and 56%; P=0.46) and in nonselective NSAID and selective cyclooxygenase-2 users (57 and 53%; P=0.32). CONCLUSION Esomeprazole (20 mg) improved NSAID-associated upper gastrointestinal symptoms. Baseline gastrointestinal risk did not influence esomeprazole effectiveness.
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Individualised PPI prescription in patients on combination antiplatelet therapy and upper gastrointestinal events after percutaneous coronary intervention: a cohort study. Wien Med Wochenschr 2012; 162:67-73. [DOI: 10.1007/s10354-012-0056-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 01/02/2012] [Indexed: 10/28/2022]
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Gastroprotection in NSAID and low-dose aspirin users: a cross-sectional study in primary care. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 35:1-7. [PMID: 22178503 DOI: 10.1016/j.gastrohep.2011.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 10/13/2011] [Accepted: 10/19/2011] [Indexed: 01/07/2023]
Abstract
Gastrointestinal (GI) complications are common side effects related to non-steroidal anti-inflammatory drugs (NSAID) and low-dose aspirin (LDA) use. The guidelines to prevent GI complications establish that patients at high risk should receive gastroprotection. However, different reports have suggested that these strategies are not greatly executed. To determine the prevalence of use of preventive strategies to reduce GI complications in NSAID and/or LDA users in primary care in Spain, we performed an observational, cross-sectional, multicentre study in which primary care physicians from Spain participated. From January 2009 to May 2009, physicians collected demographic, clinical and treatment data from the last visit in 2008 of the first 5 consecutive patients who met the selection criteria. A multivariate logistic regression was carried out to identify independent predictors of the preventive strategies used. A total of 713 primary care physicians included 3357 patients: 68% NSAID users, 19.1% LDA users and 12.9% NSAID/LDA users. 31.5% of patients did not have a risk factor for GI complications, 25.6% had one risk factor and 42.9% had 2 or more risk factors. The overall prevalence of preventive strategy use was 75.8%. The prevalence of gastroprotection use increased with the number of risk factors. The underutilization of gastroprotection in at-risk patients treated with NSAIDs is low and not as marked as those previously reported at the primary care level in other countries. We also found high rates of gastroprotection use in LDA users.
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Abstract
BACKGROUND Preventive strategies are advocated in patients at risk of upper-gastrointestinal complications associated with nonsteroidal anti-inflammatory drugs (NSAIDs). AIM To examine time-trends in preventive strategies. METHODS In a study population comprising 50 126 NSAID users > or =50 years from the Integrated Primary Care Information database, we considered two preventive strategies: co-prescription of gastroprotective agents and prescription of a cyclooxygenase-2-selective inhibitor. In patients with > or =1 risk factor (history of upper-gastrointestinal bleeding/ulceration, age >65 years, use of anticoagulants, aspirin, or corticosteroids), correct prescription was defined as the presence of a preventive strategy and under-prescription as the absence of one. In patients with no risk factors, correct prescription was defined as the lack of a preventive strategy, and over-prescription as the presence of one. RESULTS Correct prescription rose from 6.9% in 1996 to 39.4% in 2006 (P < 0.01) in high-risk NSAID users. Under-prescription fell from 93.1% to 59.9% (P < 0.01). In the complete cohort, over-prescription rose from 2.9% to 12.3% (P < 0.01). CONCLUSIONS Under-prescription of preventive strategies has steadily decreased between 1996 and 2006; however, 60% of NSAID users at increased risk of NSAID complications still do not receive adequate protection.
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Lanas A, Muñoz M, Caballero Correa M, Martínez Jiménez P. Análisis de las diferencias entre indicación y prescripción de gastroprotección en pacientes con factores de riesgo tratados con antiinflamatorios no esteroideos: estudio GAP. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:80-91. [DOI: 10.1016/j.gastrohep.2009.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 09/22/2009] [Accepted: 09/25/2009] [Indexed: 11/17/2022]
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van der Linden MW, Gaugris S, Kuipers EJ, van Herk-Sukel MPP, van den Bemt BJF, Sen SS, Herings RMC. COX-2 inhibitors: complex association with lower risk of hospitalization for gastrointestinal events compared to traditional NSAIDs plus proton pump inhibitors. Pharmacoepidemiol Drug Saf 2009; 18:880-90. [DOI: 10.1002/pds.1782] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Van der Linden MW, Gaugris S, Kuipers EJ, Van den Bemt BJF, van Herk-Sukel MPP, Herings RMC. Gastroprotection among new chronic users of non-steroidal anti-inflammatory drugs: a study of utilization and adherence in The Netherlands. Curr Med Res Opin 2009; 25:195-204. [PMID: 19210152 DOI: 10.1185/03007990802632915] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To describe the use of gastroprotection (GP) among new chronic users of NSAIDs in the Netherlands by gastrointestinal (GI) risk factor (RF) score. METHODS Data for this retrospective follow-up study were extracted from the PHARMO database. We selected new chronic users of COX-2 inhibitors (coxibs) or traditional NSAIDs (tNSAIDs) between 1st January 2000 and 31st December 2004. GP strategies were defined as: use of proton pump inhibitors (PPI), coxibs or both. GI RF score at index date was based on: history of GI drug use, high dose of NSAIDs, age > 60 years, use of corticosteroids/anticoagulants/SSRIs, rheumatoid arthritis, heart failure or diabetes, with each condition accounting for one factor. Switching was assessed among those with > or = 1 GI RF during the first year of follow-up. RESULTS Among 58,770 new chronic NSAID users at index date, 80% used tNSAIDs alone, 8% used tNSAID + PPI, 10% used a coxib alone and 2% used coxib + PPI. Mean (SD) number of GI RF among these groups was 1.6 (2.1), 3.1 (1.3), 1.5 (1.5) and 2.8 (1.3), respectively. Among 48 390 patients (82.3%) with a GI RF score of > or = 1, 20.9% used a GP strategy, this increased with number of GI RFs. Within the first year, 5.3% (n = 2067) and 4.8%(n = 1 843) of tNSAID users with > or = 1 GI RF switched to tNSAID+PPI and coxib alone, respectively. CONCLUSIONS Gastroprotection in users of tNSAIDs was inadequate. Over 80% of NSAID users with > or = 1 GI RF did not receive any gastroprotection, and even when prescribed, a PPI is used only half the time. More research should show if gastroprotection was used for prevention.
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Koncz TA, Lister SP, Makinson GT. Gastroprotection in patients prescribed non-selective NSAIDs, and the risk of related hospitalization. Curr Med Res Opin 2008; 24:3405-12. [PMID: 19032122 DOI: 10.1185/03007990802547121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess co-prescription of gastroprotective agents (GPAs) for non-selective NSAID (nsNSAID)-treated patients in UK primary care, and the rate of gastrointestinal (GI)-related hospitalizations occurring with varying levels of GPA use in patients at high Gl risk. RESEARCH DESIGN AND METHODS A retrospective, observational study was conducted using the DIN-LINK UK primary care database, on patients prescribed nsNSAIDs alone or concomitantly with GPAs between September 2003 and August 2005. Patients were stratified by GI risk, frequency of nsNSAID use and level of GPA use. Rates and odds ratios of GI-related hospitalizations were calculated for high GI-risk patients. RESULTS In August 2005, 26 371 patients with nsNSAID prescriptions were identified, of whom 55% were frequent users. In the overall and frequent nsNSAID-user populations, 74% and 71%, respectively, were co-prescribed none or few GPAs (0-19% level of use), and only 18% and 20%, respectively, received complete gastroprotection. GI risk factors were identified in 76% of all patients. Overall, 70% of patients with serious co-morbidity, 44% with GI event history, and 56% of aspirin users received little or no gastroprotection (0-19%). Data for previous months of the analysis period were similar. In patients with a GI-event history, based on data over the 2-year study period, hospitalization rates ranged from 2.4% (with full gastroprotection) to 8.0% (20-39% GPA use). Odds of a GI-related hospitalization were up to 3.5 times higher with low GPA use. CONCLUSION This study revealed low levels of GPA co-prescription for nsNSAID users in UK primary care, even among high-risk patients. Lower levels of GPA co-therapy were associated with increasing rates of GI-related hospitalization.
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Ibañez-Cuevas V, Lopez-Briz E, Guardiola-Chorro MT. Pharmacist intervention reduces gastropathy risk in patients using NSAIDs. ACTA ACUST UNITED AC 2008; 30:947-54. [PMID: 18932013 DOI: 10.1007/s11096-008-9258-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2008] [Accepted: 09/23/2008] [Indexed: 01/02/2023]
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Lanas A, García-Rodríguez LA, Arroyo MT, Bujanda L, Gomollón F, Forné M, Aleman S, Nicolas D, Feu F, González-Pérez A, Borda A, Castro M, Poveda MJ, Arenas J. Effect of antisecretory drugs and nitrates on the risk of ulcer bleeding associated with nonsteroidal anti-inflammatory drugs, antiplatelet agents, and anticoagulants. Am J Gastroenterol 2007; 102:507-15. [PMID: 17338735 DOI: 10.1111/j.1572-0241.2006.01062.x] [Citation(s) in RCA: 223] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES After the withdrawal of some cyclooxygenase-2 (COX-2) selective inhibitors, traditional nonsteroidal anti-inflammatory drug (NSAID) use has increased, but without additional prevention strategies against upper gastrointestinal (GI) complications in many cases. Here, we report the effect of antisecretory drugs and nitrates on the risk of upper GI peptic ulcer bleeding (UGIB) associated with nonselective NSAIDs, aspirin, antiplatelet agents, and anticoagulants. METHODS This case-control study matched 2,777 consecutive patients with UGIB (confirmed by endoscopy) with 5,532 controls (2:1). Adjusted relative risks (RR) of UGIB are reported. RESULTS Proton pump inhibitors (PPIs) (RR 0.33, 95% confidence interval [CI] 0.27-0.39), H2-receptor antagonists (H2-RAs) (RR 0.65, 95% CI 0.50-0.85), and nitrates (RR 0.52, 95% CI 0.38-0.70) reduced UGIB risk. PPI use was associated with greater reductions among both traditional NSAID (RR 0.13, 95% CI 0.09-0.19 vs RR 0.30, 95% CI 0.17-0.53 with H2-RAs; RR 0.48, 95% CI 0.19-1.24 with nitrates) and low-dose aspirin users (RR 0.32, 95% CI 0.22-0.51 vs RR 0.40, 95% CI 0.19-0.73 with H2-RA; RR 0.69, 95% CI 0.36-1.04 with nitrates), and among patients taking clopidogrel (RR 0.19, 95% CI 0.07-0.49). For patients taking anticoagulants, use of nitrates, H2-RA, or PPIs was not associated with a significant effect on UGIB risk. CONCLUSION Antisecretory agent or nitrate treatment is associated with reduced UGIB RR in patients taking NSAID or aspirin. Only PPI therapy was associated with a marked, consistent risk reduction among patients receiving all types of agents (including nonaspirin antiplatelet agents). Protection was not apparent in patients taking anticoagulants.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Zaragoza, Ciber Hepad, Zaragoza, Spain
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Sukel MPP, van der Linden MW, Chen C, Erkens JA, Herings RMC. Large-scale stopping and switching treatment with COX-2 inhibitors after the rofecoxib withdrawal. Pharmacoepidemiol Drug Saf 2007; 17:9-19. [DOI: 10.1002/pds.1508] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sarchielli P, Mancini ML, Calabresi P. Practical considerations for the treatment of elderly patients with migraine. Drugs Aging 2006; 23:461-89. [PMID: 16872231 DOI: 10.2165/00002512-200623060-00003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Treatment of migraine presents special problems in the elderly. Co-morbid diseases may prohibit the use of some medications. Moreover, even when these contraindications do not exist, older patients are more likely than younger ones to develop adverse events. Managing older migraine patients, therefore, necessitates particular caution, including taking into account possible pharmacological interactions associated with the greater use of drugs for concomitant diseases in the elderly. Paracetamol (acetaminophen) is the safest drug for symptomatic treatment of migraine in the elderly. Use of selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') is not recommended, even in the absence of cardiovascular or cerebrovascular risk, and NSAID use should be limited because of potential gastrointestinal adverse effects. Prophylactic treatments include antidepressants, beta-adrenoceptor antagonists, calcium channel antagonists and antiepileptics. Selection of a drug from one of these classes should be dictated by the patient's co-morbidities. Beta-adrenoceptor antagonists are appropriate in patients with hypertension but are contraindicated in those with chronic obstructive pulmonary disease, diabetes mellitus, heart failure and peripheral vascular disease. Use of antidepressants in low doses is, in general, well tolerated by elderly people and as effective, overall, as in young adults. This approach is preferred in patients with concomitant mood disorders. However, prostatism, glaucoma and heart disease make the use of tricyclic antidepressants more difficult. Fewer efficacy data in the elderly are available for selective serotonin reuptake inhibitors, which can be tried in particular cases because of their good tolerability profile. Calcium channel antagonists are contraindicated in patients with hypotension, heart failure, atrioventricular block, Parkinson's disease or depression (flunarizine), and in those taking beta-adrenoceptor antagonists and monoamine oxidase inhibitors (verapamil). Antiepileptic drug use should be limited to migraine with high frequency of attacks and refractoriness to other treatments. Promising additional strategies include ACE inhibitors and angiotensin II type 1 receptor antagonists because of their effectiveness and good tolerability in patients with migraine, particularly in those with hypertension. Because of its favourable compliance and safety profile, botulinum toxin type A can be considered an alternative treatment in elderly migraine patients who have not responded to other currently available migraine prophylactic agents. Pharmacological treatment of migraine poses special problems in regard to both symptomatic and prophylactic treatment. Contraindications to triptan use, adverse effects of NSAIDs, and unwanted reactions to some antiemetics reduce the list of drugs available for the treatment of migraine attacks in elderly patients. The choice of prophylactic treatment (beta-adrenoceptor antagonists, calcium channel antagonists, antiepileptics, and more recently, some antihypertensive drugs) is influenced by co-morbidities and should be directed at those drugs that are believed to have fewer adverse effects and a better safety profile. Unfortunately, for most of these drugs, efficacy studies are lacking in the elderly.
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Affiliation(s)
- Paola Sarchielli
- Department of Medical and Surgical Specialties and Public Health, Neurologic Clinic, University of Perugia, Perugia, Italy.
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Rey E, Elola-Olaso CM, Rodríguez-Artalejo F, Locke GR, Diaz-Rubio M. Use of antisecretory drugs among consumers of non-steroidal anti-inflammatory drugs in the general population. Aliment Pharmacol Ther 2006; 24:1585-92. [PMID: 17206946 DOI: 10.1111/j.1365-2036.2006.03173.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Overall success of prophylactic strategies against non-steroidal anti-inflammatory drug (NSAID) complications depends on the use of gastroprotective drugs. AIM We examined the use of antisecretory drugs in NSAID users in the general population of Spain. PARTICIPANTS AND METHODS In 2002, a phone interview was conducted with 2500 persons representative of the general population of Spain. Using a validated questionnaire, we asked about the use of NSAID, aspirin and antisecretory drugs, and history of digestive diseases. We estimated the use of antisecretory drugs in NSAID users, according to risk factors for gastrointestinal (GI) lesions associated with NSAID. RESULTS In total, 425 persons [17.0% (95% CI 15.5-18.5%)] were NSAID users. Of them, 69 persons (16.2%; 95% CI 12.7-19.7%) used antisecretory drugs [proton pump inhibitor (PPI) 11.8% and H2-blocker 4.9%]. Forty-four of the 224 NSAID users (19.6%) with one risk factor for GI lesions were antisecretory drug users (PPI 16%; H2-blocker 4%), compared with 24 of the 197 NSAID users (12.7%) without risk factors (PPI 6.6%; H2-blocker 6.1%). NSAID users with risk factors for GI lesions but without upper GI (UGI) symptoms did not consume more antisecretory drugs than equivalent non-NSAID users (12.9% vs. 10.7%). CONCLUSION Current strategies to prevent GI lesions in NSAID users are not effective from a population perspective, especially in subjects without UGI symptoms.
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Affiliation(s)
- E Rey
- Digestive Disease Service, Hospital Clinico San Carlos, Complutense University, Madrid, Spain.
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Moore RA, Derry S, Phillips CJ, McQuay HJ. Nonsteroidal anti-inflammatory drugs (NSAIDs), cyxlooxygenase-2 selective inhibitors (coxibs) and gastrointestinal harm: review of clinical trials and clinical practice. BMC Musculoskelet Disord 2006; 7:79. [PMID: 17054784 PMCID: PMC1626078 DOI: 10.1186/1471-2474-7-79] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 10/20/2006] [Indexed: 12/17/2022] Open
Abstract
Background Gastrointestinal harm, known to occur with NSAIDs, is thought to be lower with NSAID and gastroprotective agent, and with inhibitors selective to cyclooxygenase-2 (coxibs) at usual plasma concentrations. We examine competing strategies for available evidence of reduced gastrointestinal bleeding in clinical trials and combine this evidence with evidence from clinical practice on whether the strategies work in the real world, whether guidance on appropriate prescribing is followed, and whether patients adhere to the strategies. Methods We used a series of systematic literature searches to find full publications of relevant studies for evidence about the efficacy of these different gastroprotection strategies in clinical trials, and for evidence that they worked and were adhered to in clinical practice – whether they were effective. We chose to use good quality systematic reviews and meta-analyses when they were available. Results Evidence of efficacy of coxibs compared to NSAIDs for upper gastrointestinal bleeding was strong, with consistent reductions in events of about 50% in large randomised trials (34,460 patients), meta-analyses of randomised trials (52,474 patients), and large observational studies in clinical practice (3,093 bleeding events). Evidence on the efficacy of NSAID plus gastroprotection with acid suppressants (proton pump inhibitors, PPIs, and histamine antagonists, H2As) was based mainly on the surrogate measure of endoscopic ulcers. The limited information on damage to the bowel suggested that NSAID plus PPI was more damaging than coxibs. Eleven observational studies studied 1.6 million patients, of whom 911,000 were NSAID users, and showed that 76% (range 65% to 90%) of patients with at least one gastrointestinal risk factor received no prescription for gastroprotective agent with an NSAID. The exception was a cohort of US veterans with previous gastrointestinal bleeding, where 75% had gastroprotection with an NSAID. When gastroprotection was prescribed, it was often described as inadequate. A single study suggested that patient adherence to prescribed gastroprotection was low. Conclusion Evidence for efficacy of gastroprotection strategies with NSAIDs is limited. In clinical practice few patients who need gastroprotection get it, and those who get it may not take it. For coxibs, gastroprotection is inherent, although probably not complete.
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Affiliation(s)
- R Andrew Moore
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, The Churchill, Headington, Oxford, OX3 7LJ, UK
- School of Health Sciences, University of Wales Swansea, Singleton Park, Swansea, SA2 8PP, UK
| | - Sheena Derry
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, The Churchill, Headington, Oxford, OX3 7LJ, UK
| | - Ceri J Phillips
- School of Health Sciences, University of Wales Swansea, Singleton Park, Swansea, SA2 8PP, UK
| | - Henry J McQuay
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, The Churchill, Headington, Oxford, OX3 7LJ, UK
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Post PN, Kuipers EJ, Meijer GA. Declining incidence of peptic ulcer but not of its complications: a nation-wide study in The Netherlands. Aliment Pharmacol Ther 2006; 23:1587-93. [PMID: 16696807 DOI: 10.1111/j.1365-2036.2006.02918.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite reports of decreasing hospitalizations and mortality due to peptic ulcer, it is unclear whether the incidence has truly declined over time. AIM To investigate time trends in the incidence of and in hospital admission rates for peptic ulcer in the Netherlands. METHODS The nationwide registry of pathology reports (PALGA) and the national registry of hospital admissions (Landelijke Medische Registratie) were used. Standardized morbidity ratios were calculated to assess the magnitude of the changes. RESULTS The age-adjusted incidence of gastric ulcer halved for both men (standardized morbidity ratio 0.48; CI 0.46-0.49) and women (standardized morbidity ratio 0.49; CI 0.47-0.51). Although the number of gastric biopsies obtained at endoscopy increased, the proportion with a diagnosis of peptic ulcer decreased by more than 50% (standardized morbidity ratio 0.47; CI 0.46-0.49). The admission rate for peptic ulcer more than halved between 1980 and 2003. In contrast, admission rates for complicated ulcers barely changed and slightly increased among women. CONCLUSIONS The incidence of histopathologically confirmed gastric ulcer halved between 1992 and 2003 in the Netherlands. As the number of gastric biopsies increased in this period, a true decrease is likely. Hospital admissions for peptic ulcer declined dramatically between 1980 and 2003, but remained unchanged or slightly increased for complicated ulcers.
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Affiliation(s)
- P N Post
- Prismant, Utrecht, The Netherlands.
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N/A, 任 建. N/A. Shijie Huaren Xiaohua Zazhi 2005; 13:2597-2600. [DOI: 10.11569/wcjd.v13.i21.2597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
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